HOMEOWNER INFORMATION:

HOMEOWNER NAME:

ADDRESS:

CITY:

STATE & ZIP:
NC VA

HOME PHONE   WORK PHONE   CELL PHONE  


EQUIPMENT INSTALLED: (Must be installed by Gentry Air, Inc.) [Gentry Air, Inc. can complete model & serial numbers.]

ADDRESS WHERE EQUIPMENT WAS INSTALLED:

CITY:   ZIP:

MODEL NUMBER SERIAL NUMBER DATE INSTALLED

MODEL NUMBER SERIAL NUMBER DATE INSTALLED

MODEL NUMBER SERIAL NUMBER DATE INSTALLED

DONATION INFORMATION:

STUDENT or FAMILY NAME

DISCLAIMER (This information will be used strictly for the purpose of this donation)

         I give permission to release the name and address of the donor to Teacher Supply Warehouse

         I DO NOT give permission to release the name and address of the donor

DONATION PROCESS SUMMARY:

                                                   All Claims for donations must be submitted within 90 days of installation.
                                                     LATE SUBMISSIONS WILL NOT BE ACCEPTED, NO EXCEPTIONS!